Group Frame of Reference Presentations and Documentation Notes

Group Frame of Reference Presentations

  • Overview

    • Weeks 10 (Sept 24) and Week 11 (Oct 1) labs will feature Group Frame of Reference Presentations. ©2018 Stanbridge University

  • Presentation Instructions (pg 14 of the syllabus)

    • Students will work in assigned small groups of 4−54-5 students to present a Frame of Reference to peers.
    • Presentations will include a PowerPoint or Prezi and must explain the main concepts of the frame of reference as they relate to occupation.
    • Presentations are to be 2020 minutes in length. Points will be deducted for presentations that are less than or exceed time limitations (a 11 point deduction for each minute over or under).
    • PowerPoint handouts are to be turned in at the time of the presentation. Please follow the assignment rubric and use the checklist to ensure you have completed all requirements. ©2018 Stanbridge University

  • Group Frame of Reference Presentation Criteria and Scoring (pg 3)

    • Content
    • Introduction/Conclusion are present: /5/5
    • Main Concepts from theory are presented and explained well: /5/5
    • Fictional case study is presented to demonstrate appropriate integration of FOR: /5/5
    • Organization and Slides
    • Slides/Presentation are visually pleasing and easy to follow: /5/5
    • Team and Timing
    • Team effort is clearly identified: /5/5
    • Presentation length is within assignment requirements: /5/5
    • Verbal & Nonverbal Delivery
    • Volume and Enunciation is appropriate and clear: /5/5
    • Open body language with good eye contact: /5/5
    • Audience Participation
    • Engaging Activity presented: /5/5
    • Activity is creative and appropriately connected to the topic: /5/5
    • Total: /50/50
    • ©2018 Stanbridge University

  • FOR Peer Evaluation (pg 4)

    • Each student will independently evaluate each FOR presentation using rubric provided.
    • Respectful, constructive, detailed, and accurate feedback is expected. Points will be deducted for feedback that does not meet these expectations. ©2018 Stanbridge University

Documentation Fundamentals and Guidelines (Week 8-9)

  • Documentation quotations and framing (Week 8-9)

    • "If a tree falls in a forest and no one is around to hear it, does it make a sound?" — George Berkeley (Version 1)
    • "The health record is a communication tool while the client is receiving services, but it is also the source for financial, legal, and clinical accountability." (Gateley & Borcherding, 2017) (Version 1) [Image from unsplash.com]

  • Musts of OT documentation (Gateley & Borcherding, 2017) (Version 1)

    • Must contain:
    • What services were provided and when they were provided
    • What was said and what happened
    • How the client responded to the service provided
    • Why the skill of an OT is required rather than the services of an aide, a family member, or another professional
    • ©2018 Stanbridge University

  • Assumptions Before Writing (Gateley & Borcherding, 2017) (Version 1)

    • Before you write anything in the record, make these assumptions:
    • Someone else will have to read and understand what you write because you may be sick or out of town the next time the client needs to be treated.
    • The entry will be scrutinized by a third-party payer. If you were a Medicare reviewer, would you want to pay for the services you are about to record?
    • Your client will exercise their right to read this record.
    • ©2018 Stanbridge University

  • Documentation Reminder (Week 8-9)

    • Your documentation is a reflection of your professional identity and abilities. (Gateley & Borcherding, 2017)
    • Photo by Baran Lotfollahi on Unsplash

  • AOTA Guidelines for Documentation (AOTA, 2013) — 15 Fundamentals

    • Client identification
    • Date and time
    • Type
    • Signature
    • Placement of signature
    • Co-signature
    • Compliance
    • Terminology
    • Abbreviations
    • Corrections
    • Technology
    • Record Disposal
    • Confidentiality
    • Record Storage
    • Clinical reasoning and expertise
    • ©2018 Stanbridge University

  • General Guidelines (Paper Chart) — (Page 12)

    • Use waterproof, nonerasable black ink
    • Sign and date every entry
    • Identify the client on every page of documentation
    • Be as concise as possible without leaving out pertinent data
    • Use only abbreviations approved by the facility
    • Document on time (Gateley & Borcherding, 2017)
    • Photo credit: Google Images

  • General Guidelines (Page 13)

    • Correct errors
    • Comply with policies, rules, and laws for confidentiality
    • Be aware of “red flag” words, such as continued and maintained
    • Show the clinical reasoning of the OT practitioner and why the skills of an OT are necessary for the client (Gateley & Borcherding, 2017)
    • Photo credit: Google Images

  • Correcting Errors (Gateley & Borcherding, 2017) (Page 14)

    • Only correct your own errors, never someone else’s
    • Never hide the error by completely crossing it out or using correcting fluid
    • Electronic health record: Add an addendum to the original indicating the error and the correct information
    • Handwritten documentation: Strike through the error (single line), make correction, record the date and time of the correction if the facility requires it
    • Photo credit: Google Images

  • Avoiding Common Documentation Errors (Gateley & Borcherding, 2017) (Page 15-18)

    • Quotation marks when documenting the exact words a client or another person said:
    • Incorrect: Client stated I can’t feel my left arm.
    • Correct: Client stated, “I can’t feel my left arm.”
    • Do not use quotation marks when paraphrasing what a client or another person said:
    • Incorrect: Client reports he “can’t feel his left right arm.”
    • Correct: Client reports he cannot feel his left right arm.
    • Photo credit: Afif Ramdhasuma on Unsplash

  • Verb Tense and Consistency (Page 16)

    • Be consistent with verb tense:
    • Incorrect: Client demonstrated upper body dressing with min A. Client threads R UE inter sleeve first. Client transfers to toilet with SBA. Client completed grooming tasks independently.
    • Correct: Client demonstrated upper body dressing with min A. Client threaded R UE into sleeve first. Client transferred to toilet with SBA. Client completed grooming tasks independently.
    • Photo credit: Unsplash

  • Plurals and Possession (Page 17)

    • Plurals: add an “s” to indicate plural and avoid apostrophes for plurals
    • Incorrect: The client’s participated in a group discussion about time management and ADLs. The OT’s then provided additional suggestions.
    • Correct: The clients participated in a group discussion about time management and ADLs. The OTs then provided additional suggestions.
    • Possession:
    • Incorrect: The clients’ spouse was present during the session
    • Correct: The client’s spouse was present during the session
    • Plural possessive (three clients):
    • Incorrect: The three clients group discussion focused on coping skills.
    • Correct: The three clients’ group discussion focused on coping skills.
    • Photo credit: Google Images

  • Capitalization and Spelling (Page 18)

    • Follow general rules for capitalization (Table 4-1 of Gateley & Borcherding)
    • Know the appropriate spelling of commonly misspelled words
    • Know the rules of abbreviations for your facility
    • Photo credit: Google Images

  • Documentation Fundamentals (Week 8-9) — Summary (Page 19)

    • Kelcie Kadowaki, OTD, OTR/L; Stanbridge University

Occupation-Based Problem Statements (Gateley & Borcherding, 2017) (Pages 20-25)

  • Step 1: Identify the occupation impacted by the client’s condition

  • Step 2: Identify the contributing factors that limit engagement in the desired occupation

  • Writing Functional Problem Statements (Pages 21-23)

    • Areas of occupation include: ADLs, IADLs, Rest and Sleep, Education, Work, Play, Leisure, Social participation
    • Examples of occupation-based problem statements: "I want to walk" → "I want to attend my granddaughter's graduation"; "I want to be able to cook for myself"; "I want to visit my motherland one more time"; etc.
    • Contributing factors to identify: Client factors, Performance skills, Performance patterns, Context and environment
    • Description and definitions (Page 24):
    • Client factors: “…specific capacities, characteristics, or beliefs that reside within the person…” (AOTA, 2014, p. S7)
      • Values, beliefs, and spirituality
      • Body functions
      • Body structures
    • Performance Skills: “goal directed actions that are observable as small units of engagement in daily life” (AOTA, 2020)
      • Motor skills
      • Process skills
      • Social interaction skills
    • Performance Patterns: Patterns of behavior related to the activities of an individual, organization, or population
      • Habits, routines, rituals, roles
    • Contexts and Environments: Interrelated conditions within and surrounding the client
      • Cultural, personal, temporal, virtual, physical, social
    • Identify the contributing factors to limit the engagement in the desired occupation
    • Copy Right Stanbridge University

  • Writing Functional Problem Statements (Pages 25-31)

    • Identification of: Area of occupation, Contributing factors, Measurement, Cause
    • Example structure templates:
    • Client is unable to (engage in what occupational task) due to (contributing factor).
      • Example: Amy is unable to do jumping jacks to participate in gym class due to motor planning deficits.
    • Client requires (assistance level) in (performing what occupational task) due to (contributing factor).
      • Example: Sam requires moderate assistance to hold scissors to complete art activities in school due to increased tone in right UE.
    • (Contributing factor) results in (what occupational deficit).
      • Example: Three steps leading to front door limits Mr. Smith’s independence in entering his home.
    • Client is unable to dress self independently due to decreased active range of motion in bilateral upper extremities.
      • Ask: What is the area of occupation? What is the contributing factor?
    • Client is unable to complete laundry tasks due to lifting restrictions in post-surgical back precautions.
      • Ask: What is the area of occupation? What is the contributing factor?
    • Robin's story: OT and amputations
    • What is this client’s area of occupation? What is the contributing factor? What would be an appropriate functional problem statement?
    • Child with Brachial Plexus
    • What is this client’s area of occupation? What is the contributing factor? What would be an appropriate functional problem statement?
    • Copy Right Stanbridge University

  • References

    • Gateley, C., & Borcherding, S. (2017). Documentation manual for occupational therapy: Writing SOAP notes (4th ed.). Thorofare, NJ: SLACK, Inc. (ISBN: 978−1−63091−231−4978-1-63091-231-4)
    • ©2018 Stanbridge University